Receiving treatment

Published on 09/04/2015 by admin

Filed under Hematology, Oncology and Palliative Medicine

Last modified 09/04/2015

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21 Receiving treatment

Case update

Two weeks after diagnosis, Michelle undergoes a left mastectomy. During the surgery, a sentinel node biopsy is taken to see if the cancer has spread to any of Michelle’s axillary lymph nodes. Two of the nodes are found to be positive. Immediately after surgery, the tissue that was removed from Michelle’s breast is tested for receptors, to see if the cancer is responsive to hormones (oestrogen and/or progesterone) and to see if there is overexpression of HER2 receptors. She is found to have an oestrogen-positive cancer, however the cancer is not overexpressing HER2 receptors nor is it progesterone responsive. The cancer is then staged as follows:

• The size of the cancer was 2   cm in diameter.

• Two lymph nodes (glands) were positive under the arm.

• The grade of the cancer (how aggressive the cancer is) was assessed to be grade II (intermediate aggressive in appearance).

The Nottingham Prognostic Index (NPI) is calculated as 4.4. This means that Michelle has an intermediate chance of being cured. She will, therefore, require adjuvant treatment to reduce the risk of recurrence.

Michelle makes a swift recovery from the operation and is able to go home the following day to recuperate. Before her discharge, she is seen by the breast nurse specialist who fits Michelle with a soft prosthesis which slips into her bra. She can wear this as soon as she feels comfortable. The breast nurse arranges an appointment for Michelle to return for a proper prosthetic fitting as an outpatient. She is also seen by the physiotherapist who teaches her some arm exercises that she should do daily to maintain the strength and flexibility in her left shoulder and arm.

image Activity

Postoperative care

Summarise the main physiological processes involved in wound healing. Identify the most conducive environment to prompt healing following a surgical procedure.

Write a care plan for Michelle’s immediate postoperative care required.

Consider the importance of accurate and thorough documentation of healthcare activity and events. Refer to the Nursing and Midwifery Council (2009) Record Keeping: Guidance for Nurses and Midwives:

http://www.nmc-uk.org/Documents/Guidance/​nmcGuidanceRecordKeepingGuidanceforNursesandMidwives.pdf (accessed November 2011)

NMC Domain 1: 1.2; 1.3; 1.4; 1.5; 1.6; 1.9

NMC Domain 3: 3.1; 3.2; 3.3; 3.4; 3.5; 3.6; 3.7; 3.8; 3.9; 3.10

Further reading

Hughes E. Principles of post-operative patient care. Nurs. Stand. 2004;19(5):43–51. 53, 56

Thompson A.M., Wells M. Surgery. In: Kearney N., Richardson A. Nursing patients with cancer: principles and practice. Edinburgh: Churchill Livingstone, 2006.

Points to consider

The postoperative period can be extremely challenging. There are many immediate and long-term issues to deal with. Directly after surgery, the focus must be on the physical health status of the patient: oxygenation of tissues; respiratory and cardiovascular function; fluid balance; infection control; pain management; body temperature, etc. These all need careful monitoring. There are many implications of surgery in the longer terms, such as adapting to the physical appearance and/or the physical function. These may be unexpected (even if the patient was informed preoperatively) and can be extremely difficult to deal with.

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Discharge

Draft a discharge plan for Michelle, or identify a patient who you have discharged home following a hospital admission, and reflect on the planning involved. Consider: what rehabilitation do they require? Are there any household alterations required before discharge? Which other multiprofessionals need to be involved? What information does the patient and their family need? Is transport required? What medications does the patient need once at home? Are any referrals to community services required?

NMC Domain 1: 1.2; 1.3; 1.4; 1.6

NMC Domain 2:2.1; 2.2; 2.3; 2.4; 2.6; 2.7; 2.8

NMC Domain 3: 3.1; 3.3; 3.4 3.5; 3.8; 3.9; 3.10

NMC Domain 4: 4.7

Further reading

Royal College of Nursing. Day surgery: discharge information. Online. Available at:. 2004. http://www.rcn.org.uk/__data/assets/pdf_file/0011/78509/001376.pdf (accessed May 2011)

Points to consider

The transition from hospital to home can be quite anxious for most patients. Leaving the security of the specialised healthcare environment can feel isolating and scary. Patients need good information about: who to call if they experience any complications; what they should/should not do once they get home; what rehabilitation exercises will assist their recovery; which medications they should take and how often; when they need any sutures/clips removed and who will do this; when they need to return for a follow-up appointment, etc. Although most patients prefer tailored information, there is so much information to take in that patients should be given a written record as well.

The role of the nurse is essential in providing supportive care. As hospital stays decrease, there is an increased need for community nurses to become more knowledgeable and skilled in caring for postoperative patients.

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Psychological impact of surgery

Think about the changes in Michelle’s body appearance after the loss of a breast. How might her perception of her body alter? How might this affect her confidence and sexuality as well as her social situation?

Write a reflection on an observation/experience you have encountered where a patient underwent surgery and their body image was altered. What could have been done to minimise this impact and what can be done to aid adjustment?

Register on Macmillan’s ‘Learn Zone’ on their Website:

http://learnzone.macmillan.org.uk (accessed November 2011)

Follow the tabs to the ‘Health and social care professionals’ section, scroll down to the ‘Body image’ course and work through the exercises.

Think about what might be concerning Simon regarding his relationship with Michelle. Find an article that considers how partners might feel when their spouse has undergone surgery.

NMC Domain 1: 1.2; 1.3; 1.5; 1.6; 1.9

NMC Domain 2: 2.1; 2.2; 2.3; 2.4; 2.6

NMC Domain 3: 3.1; 3.3; 3.4; 3.5; 3.8; 3.9; 3.10

NMC Domain 4: 4.2

Further reading

Chan L. Body image and the breast: the psychological wound. J. Wound Care. 2010;19(4):133–138.

Price B. Understanding patient accounts of body image change. Cancer Nursing Practice. 2009;8(6):29–34.

Points to consider

The time patients spend in hospital postoperatively is very brief, therefore it is important to prioritise their needs while they are on the ward and plan discharge from the outset. Depending on patients’ needs and the surgical procedure they have undergone, close liaison with other agencies, such as the GP, community nurses, occupational therapies, physiotherapists, pharmacists, social workers, etc., is paramount to ensure patients are safely discharged and supported once at home.

Partners, family members and informal carers can find it particularly difficult and confusing once the patient is discharged home. It is a daunting prospect being a carer: not knowing what to expect, worrying that the patient may be in pain and that you are being depended upon. There is often a temptation to want to smother or wrap the patient in cotton wool. This can be frustrating for the patient who may want to regain independence as soon as they are physically able, and may feel that their rehabilitation is hampered. It can also be difficult for partners to feel physically close to the patient, even when wounds have healed. They may fear causing pain or harm to the patient. Sometimes these anxieties continue for a significant length of time and can affect relationships and feelings of intimacy in the long term.

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Cytotoxic therapy

Look up and make a list of the side effects of 5-FU, epirubicin and cyclophosphamide. What side effects is Michelle likely to experience? Identify strategies that prevent/minimise these toxicities.

Write a reflection on one or two patients you have cared for while, or after, they received cytotoxic therapy. What toxicities did they encounter? How were these assessed and managed?

What antiemetic is Michelle likely to be prescribed alongside this regimen?

What advice should Michelle be given to reduce her chances of getting an infection while she is receiving cytotoxic treatment?

What signs and symptoms of infection should Michelle look out for? Who do patients need to inform in your area if they suspect they have a temperature?

How might Michelle feel about losing her hair? What are the local arrangements for patients to obtain a wig? Find out about scalp cooling in your area.

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